Precision Regenerative Medicine with Dr. Tammy Penhollow

Dr. Tea  0:00  
Owners of a direct care practice are more likely to experience higher job satisfaction than the insurance based practice. And it's no wonder why direct care is independent of insurance. Patients pay the doctor directly for their expertise. The doctor gets full autonomy in how they care for patients and how they get paid. They have chosen this path with a love of medicine. This is The Direct Care Way. 

Dr. Tea  0:24  
By listening to this podcast, you may even start to believe that you too can have a successful direct care practice. Come listen with an open mind as I share my personal journey and how I pivoted from an insurance based practice to direct care right in the middle of the pandemic, and the valuable lessons along the way. This podcast may be the very thing you need to revitalize your medical practice. I'm your host, owner of a direct care podiatry practice Dr. Tea Nguyen.

Dr. Tea  0:52  
Today I have Dr. Tammy Penhollow, who is an anesthesia doctor? A DO and I have a great heart for DO, I married one if you didn't know a General surgeon - DO. Hey. And so I have here Dr. Penhallow who's going to share with us her journey into her direct care practice, what that looks like and how you can do it to welcome Dr. Tammy.

Dr. Penhallow  1:13  
Thank you so much. Dr. T. It's fantastic to meet you in person. I've been following you for quite some time. So it's truly an honor. And go to

Dr. Tea  1:21  
Yeah, you too. Because I see you on LinkedIn and you have a regenerative practice in Arizona. Why don't you take us back to how you pivoted from insurance based medicine and into your practice. And you also mentioned that you are a 1099 for locums. And how does that really work? So I know that was a whole bunch to throw at you starting where you want.

Dr. Penhallow  1:42  
I'll start with I was a traditional pain doc trained in the Navy and trained at Stanford. That's important because they say on a console that Stanford is people who've been to maybe 15 Docs, they're the zebras are the people who have been everywhere, and they're just at their last hope. And we sat down for a good hour. We approach them from a bio SoCal social psycho standpoint. We had conferences on these patients, and there was pain psychology, there was physical therapy, occupational therapy, there was the pain, Doc, and it wasn't about meds, and it wasn't about surgeries. Honestly, we would do those kinds of things. But the goal was to get people to the highest level of function. So I purchased a practice in San Francisco after that, and ended up long story short, it wasn't what it was built to be. And I left it, I came to Arizona and joined a very large group where there were pain Doc's and there were orthopedic surgeons of all different specialties. And was going okay for a while, I guess, okay, and that my minor was seeing patients, I was able to do some procedures and get some people semi better. But it came down to the point where they said, Look, you're not seeing enough patients, you're not seeing enough volume. You would like your one hour consults and your 30 Minute follow ups to become 30 minutes and 15 minutes respectively. And I simply couldn't do that. People come in with a couple shopping bags full of drugs, just to get through the list of your meds and what needs to be refilled, et cetera, wasn't, I wasn't going to let that happen. I was going well over time and they said that if I don't pick it up, I'm going to have to start paying them because I'm not making enough money. So I quit, walked away. 100% said no more pain. I've got to figure this out. So I leaned on anesthesia and went back to an anesthesia practice. 

Dr. Penhallow  3:41  
And to answer the second part of your question before I come back to the first within that I knew that I didn't want to be under somebody else's umbrella where I was producing revenue, revenue revenue and they are telling me when to work where to work, nights weekends, holidays, it mean anesthesia is basically can be 24/7 babies are born whenever so there's OB anesthesia surgeries happen whenever so there's anesthesia that needs to cover that. So it was more of a 1099 independent contractor directed practice where I could say I'm available this day this day in this day, and could even walk away from a situation if it wasn't safe if I was being asked to direct too many nurse anesthetists beyond what CMS allows if I was being asked to do anesthesia in unsafe situations, so I liked the independence. I liked the ability to practice the kind of safe medicine that I believed. At the same time it allowed the flexibility to come back into pain management, but on my own terms. Everybody talks about life on your own terms or practice on your own terms with direct care and developing a regenerative medicine practice. was about going back to my osteopathic roots, not destroying joints anymore with steroids not burning the nerves that go to those joints in the back or the neck and then making the muscles weak wasn't about being the surgeon that I was before implanting drug pumps, you know, that would drip down hydromorphone, or morphine or numbing medicine on the spinal cord, 24/7, or implanting spinal cord stimulators, I had a very large surgical practice in San Francisco. And I knew again that this was all Band Aid stuff. It wasn't about putting the body in the right frame to heal itself. And I know with regenerative medicine, guess the definition, we'll be using the body's own forces, own cells to promote healing, reduce inflammation, reduce pain, and more importantly, improve function. 

Dr. Penhallow  5:55  
And that's why I went into medicine in the first place not to put people on super high doses of opioids or become the number one opioid prescriber in the state of Arizona in my first year in practice, which is unfortunately, what happened in that old model. So I do this using the patient's own cells, but only now after their cells are healthy. So I don't just meet, you have a consultation and say, Okay, let's draw your blood, let's put it in that joint, and into the ligaments and tendons around it, etc. It's like, Let's optimize you. First, let's look at your diet, let's look at your, your weight, let's look at your other habits, and let's reduce your inflammation so that then we can harvest your now less inflamed blood less inflamed bone marrow or fat, and precisely deliver it to where you got these injuries. So that has allowed me to return to the kind of medicine I want to do and the medicine I love. And anesthesia has kind of been that buffer for me or kind of allowed a little bit of a transition up as this ramps up, and then hopefully anesthesia will go down. And this will be everything.

Dr. Tea  7:02  
You're speaking my language trying to get patients back to where they can heal and be independent of self efficacy where they don't have to come through the practice through like a rotating door and finally get to heal. And I think that's what's missing. I think we all know that's what's missing in traditional medicine is that the time that we need to spend has been truncated to maximize dollars for the CEOs for the administrators, which has nothing or if anything, hurts medicine, it hurts the people we're trying to take care of. So that's where I see a huge conflict in the insurance based practice, not to say that they don't have a role in the bigger things, trauma care, like you said, babies coming out stuff like that. But for the work that we do, it's a lot more elective, people can choose that they know the price of things. It's more than just a band aid to get you in and get you out. And you know, each time you do that it's a transaction and it ends up being very costly for the patient because we never get to the root of it. So you went from anesthesia, you went to your pain specialty, but then you left that employed position. And now you're doing locums as a 1099. And just in case you don't know what a 1099 is, that's when you're an independent contractor. And you pay your own taxes on that you're not technically you're not employed by anybody, which means you can set your own schedule, but you're also responsible for those financial obligations. Malpractice probably really depends on your situation. We have a situation in podiatry where some people are 1099. But they function as an employee, and there's legal issues around that as well. But in your situation, where does the 1099 work for you in what you do? And how does it work with or against building your direct care practice?

Dr. Penhallow  8:56  
So the 1099 is only on the anesthesia side. Otherwise, I have my own corporation for well, I've got several corporations. One is anesthesia based and one is direct care, regenerative medicine based practice. So that 1099 For me as a true 1099 Not an employee because there that's a big definition and there's IRS definition in their state to state definitions. So for me, it allows the flexibility to put the time and effort and energy into building my regenerative practice, my direct care practice and not worry about having already booked a month out or two months out or knowing that I'm taking you know call for somebody else. There is no call, there are no nights, there are no weekend's no holidays, unless I decide to work something like that to gain a little extra money to then funnel back into this direct care practice. So for me it has been very easy and I can't see doing a W two anesthesia employed model and this practice because you know what would get pushed out? It'd be my passion. So it's been very good for that. And from the standpoint of owning the regenerative medicine practice and being the solopreneur, the solo operator that is more of the How to small business owner and taxes are a little bit messier, I guess then, you know, being able to TurboTax things so I've had a great CPA all along ever since I had the practice in San Francisco. So I know the benefits of maximizing those kinds of things with individual 401 k's and allows the ability to contribute that way and kind of get into alternative investments which can be faster growing. So I always want to keep this kind of structure, corporate lies. 

Dr. Tea  10:52  
Your 1099 is you as an independent contractor with Is it the hospital is that with the anesthesia group

Dr. Penhallow  10:59  
Variable. I work with a couple of locum companies so I'm 1099 with a locum but I will go specifically to a hospital in northern Arizona for example. And the assignments are through the locum group. The pay is through the locum group but I will show up at the hospital and work those you know those times next week I go up and it's Monday through Friday 7am to 7pm. So I show up on a Sunday, I stay in a hotel for a week, my drive back home on a Saturday and I've knocked out 60 hours in a week. And then all that comes through the locum company and I get a 1099 at the end of the year on another job stack. I work locally with an anesthesia group. That service is mostly endoscopy centers. And that is not a I do my own cases for anesthesia it is I will medically direct nurse anesthetists in endoscopy centers, or they'll give an assignment in our reproductive like an REI clinic for harvesting eggs for fertility or podiatry, or whatever, where they give me an assignment and I can do my own cases in that situation. So again, I've told them when I'm available, I don't have any benefits from their standpoint, I get a 1099 from them. 

Dr. Tea  11:06  
Do you build out any insurance codes? Do you have to use your NPI? Or are you like, I guess it's salary, not salary, but just your time? Not billing insurance? Is that correct? 

Dr. Penhallow  12:26  
Correct. There are billing companies on that hospital side in northern Arizona, there are billing companies with this anesthesia group that take care of everything. So I'm sure my NPI is exposed. And it's just a matter of knowing that when I'm in my pain practice, it is completely separate. If somebody sees me on a network for a blue or a Humana or whatever, name big insurance, and call and say hi, see you're on network. But it's not on network for pain, because regenerative medicine is not covered. It is simply not covered. And I don't want it to be honest but they you know, they understand we have a conversation. But still I get somebody to sign an ABN, whether they be Medicare or not. It's and that way, I just kind of cover myself at the very first meeting, even before I have a meeting with them. I talked to them and I send them some information, you know that regenerative medicine is a non covered thing. And this is a self pay practice. So just so there's no confusion at the end, just so somebody doesn't say, Hey, can you give me this super bill, and they can submit it themselves. But these are non covered things. So I say you're not going to have them signed, I will not submit this to my insurance. I understand this is not covered by insurance by signings here on this date, this time this amount was paid, I will not be doing this.

Dr. Tea  13:43  
So you have a distinction, which I think is really important to point out because a lot of people are uncertain about opting completely out, they need some financial revenue, they need to have security and so I agree that the hybrid option either you're slowly opting out of insurances you already have or you can do what you were doing here, which is locums. If locums is available, then recognize that you have to know your contract that they're if they're billing with your NPI, that also means that you're bound to that contract, whether you're working at that system or in your private practice. So having this clear delineation where you're doing anesthesia as locums versus a self pay type of practice and for you it's regenerative medicine and that's similar for many practices so we know that they're regenerative things that we offer are not covered. Have you ever had any situations that complicated that for you?

Dr. Penhallow  14:37  
I've had people even who have signed the piece of paper say, you know, I'd like to submit this to my insurance. I said, you signed here that you have not this is a part of your record. I've given you a copy of this. You cannot so I've had a couple of Medicare Advantage programs, call me and say Hi, are you still on? Bla bla bla insurance and you've got one of our beneficiaries who's submitting for reimbursement. I said I have had many discussions with said person and can document and have documented and they recognize that what I have done with them and for them is not covered. This is a non covered procedure. It's a non covered aspect of medicine, and I am not going to submit things. And they're not going to submit things where we'd like you to fax over your records, I'm not going to provide that the patient has access to their electronic medical record, they have access to their own portal, they can submit these things to you. Obviously, they are their own things I'm not encouraging them to, but they have the right to provide their records to whomever. But the patient has been counseled and has signed documents that say they will not be submitting this to insurance. So I've that's the kind of engagement I've had on a couple occasions. And it's only happened two times since 2019. So not bad.

Dr. Tea  15:54  
Yeah, I feel like that's still a waste of your time. You already said what you needed to say. 

Dr. Penhallow  16:00  
Of course. 

Dr. Tea  16:00  
So let's circle back. So how did you decide to open your direct care practice? And how long has it been?

Dr. Penhallow  16:08  
I decided to come back into pain medicine in about 2019. I've been interested in and attending CMEs for and learning about and doing, you know, actively in in classes, excuse me, like in conferences, the regenerative medicine stuff, it's not just about taking PRP or bone marrow derived mesenchymal cells or adipose derived mesenchymal cells and putting them the same exact targets. It's a whole, it's a whole super specialty within a specialty. I think ultimately, there might even be a board for it. I don't care that there is one because that's all related to insurance and credentialing. But it's educating myself and knowing that that's the way I would want to come back into medicine. And if I wasn't able to do regen, then I wouldn't do pain at all. Because I know what the traditional pain model is 

Dr. Tea   17:04  
How long does it take for you to get to a steady state, or are you still building and developing? What does that look like from 2019 to now we're in 2024,

Dr. Penhallow  17:13  
it is not where I want it to be at this point, I would like to steepen the curve and increase the growth trajectory. So it's not flat per se, but certainly doesn't have the slope that I would prefer it to. So it has been a lot of trial and error, it has been a lot of in I guess you can never say something was completely a waste of your time and effort because you always learn something out of it. But 10s of 1000s of dollars in, in marketing, that head did not have any ROI. And I think sometimes as physicians we are seen as a big huge red target, well, maybe a money sign target that says go after this one market to this one, fall into that trap and you know, $49 consults to get people in the door and people there. You know, the psychology of that is that people don't value $49. Certainly it's not worth my time to even take a consult for $49. But did I do it in the beginning? Sure. So I've learned so I think that I'm here in terms of intellectual and emotional intelligence regarding marketing regarding business. And all the other lessons I've learned are not transferred into the kind of fully independent practice that I would want at this point that That's the sign of full success for me is up, I'm not doing anesthesia anymore. So clearly I am at this point, but I am making motions. Now I'm moving the needle better already in 2024. Then, in 2023, 

Dr. Tea   18:55  
You had mentioned you spent a lot of money in marketing, what works, what didn't work

Dr. Penhallow  19:00  
What didn't work for me or Facebook and iG. Those social media platforms did not tend to send any qualified leads. There are leads and there's qualified leads. And there's pre qualified leads and there's those kinds of things. So I would say that that did not work. I am kind of hamstring by the fact that this is regenerative medicine with regard to Google ads, because anything platelet rich plasma bone marrow etc even if it was prolotherapy I'm finding is something that I would have to have people land on a completely separate landing site because regenerative is in my name and precision regenerative medicine. So if it lands on my original web page, that's an issue so I can't advertise that way. So that hasn't worked. Other things that haven't worked great are taking out an ad at a gym or being on a 12 by 17 billboard at the gym. Word there's a certain one Chiro one podiatrist one massage therapist one pain doc one, whatever can can choose a place at that gym, I got zero leads from that even going in person, they had monthly ability to go in and be face to face with people, you know, people stopped by your booth that didn't get me much. I've been in a couple of golf magazines that are all over, you know, this part of the valley hasn't gotten any leads from that because I do ask where we've come from, where I have seen a lot of traction is face to face referrals. It's a patient who's done well, who talks to their friends and family. So my marketing is providing the best kind of medicine that I can, the personable kind of medicine, you can do that. And in our console, you can do that in and follow up with people, you can do that in just your structure and your morals, your values. So I put more time into just nurturing the relationships I have with the patients I have. And that's already doing. I think it's doing the highest amount. Um, networking is another one, I know that you've done a recent podcast on that, and showing up and showing up and showing up and showing up and not expecting it to happen the first time, but monthly meetings or the quarterly meetings and just getting to know people and how can I help you? Right there. There are some issues that I had to get over regarding if you're in an insurance based model, or you always hear about what's my referral fee? What's my referral fee? And I was appalled when people would say, Well, what's my referral fee? I'm like, Are you kidding me? I do not look at an orange. I did not care to go to jail. Are you talking about me paying you to send me a patient? I don't get no, you know, just understanding that in a non insurance based model that there can be some, some incentives for referrals. I'm not saying throwing out cash at somebody, but there can be some benefits for mutual referring to each other. Whether that, you know, I don't know, I haven't quite figured out exactly what that looks like. But I'm exploring that further.

Dr. Tea  22:09  
That's a good point, I had thought about referral benefits. When you're in the insurance model. There's the Kickback Statute where we cannot refer if we are dealing with Medicare, because it's a government program. And if you demonstrate kickback, a lot of legal actions can be held against you. But I didn't know that medicine existed in medicine. But I think I found on the AMA that they said it's just an unethical thing to do. Like don't bother, you know, people shouldn't come to you because they're incentivized, except we're entering a generation where the people are only talking about products promoting products, if they're going to get an incentivize a bonus out of it or something, which is we're at a really weird place. Social media right now, where people are pushing for things in which they get kickbacks for. And it's indirect. And I don't know, I don't know how I feel bad. That's gonna be a whole other episode because I because then you start entering the realm of is that even ethical? Would you refer? And if you didn't get a benefit, is that professional, you're a doctor, shouldn't you be non biased, but then you're looking at the system, you know, insurance based system, everybody gets a kickback. If you're looking at an HMO system, they cannot refer out because that money is drained from the system. There are systems out here that won't refer to me because I'm not within their network. But I do think that they don't do so anyway. 

Dr. Penhallow  23:29  
No, it's one of those things that I haven't figured out yet either. But it is definitely out there. And I know that you know, whether that's the you know, the good ol boys deals are made on the golf course thing or if it's out in front of, you know, where people talk about, if you click on this link, then I get a referral. Or this is definitely uncharted territory for me.

Dr. Tea  23:58  
But going back to what does work, I, I agree with you, I also spend lots of money on marketing and at the end of the day, it's the relationships you have with your patients or your referral network and you're solving problems that they can't take on and so they rely on you for that. So I do think investing time to build those relationships are really important. So building a direct care practice there are some challenges but what has been your biggest win

Dr. Penhallow  24:23  
Coming back into regenerative medicine or coming back into pain medicine but via region because there's a reason I went into it for the first place I'm I was drawn to pain medicine as and before I even pivoted from dermatology to anesthesiology in the Navy and said I signed me up for anesthesia residency we just taken Volusia we were having a whole bunch of people three times a week coming in on airplanes from the Middle East that were broken and severely wounded with multiple limb injuries and how would I help them As a Derm, I could help them as a pain doc. And that's what drove me into pain in the first place. So to have stopped that, and walked away, was like I wasn't fulfilling my purpose. So coming in to regenerative pain as a direct care practice, and I think that's a big win, because it keeps me in the whole reason that I went into pain in the first place. And it allowed me to be a DO and apply those skills, the holistic aspect of things, and it provides a lot of flexibility. And I've had some great wins with patients who are not just medicated in the corner, they're actually making big changes, like returning to marathons after a rupture or partial rupture, or not full rupture of a plantar fascia returning back to playing with their kids or playing with their grandkids after, you know, two or three disc ruptures in the lumbar spine. So I think that those are the big things. I mean, it's put me here in the first place,

Dr. Tea  25:58  
do you have any regrets,

Dr. Penhallow  25:59  
I purchased a machine, one of those bright and shiny object things that I thought I was going to use in a regenerative fashion. It was technically marketed for aesthetics, but I'm using it still, for building muscle and stabilizing the spine and developing that core, like my Tower of Power. So do I feel like I was very naive and kind of got into a four year horrible, horrible equipment lease thing on it? Yeah, that's probably a big regret there. But a lesson learned. No, but an expensive, expensive lesson learned.

Dr. Tea  26:34  
I don't think you're alone on that one. I think a lot of us, you know, it's easy to want to find that singular solution and realize it just ended up being more expensive than we anticipated. Myself included,

Dr. Penhallow  26:47  
I never knew that it was going to be the one thing like that one thing, but just to augment and just make things so much more whole, you know, coming at it from that holistic standpoint, that boy, wouldn't this be great to use it in this fashion. But, you know, in order to make that happen, it was then you go down in the Facebook and iG routes and you're advertising the plastic stuff, it's cosmetic, it's all these things. So the whole plastic thing, I'm not plastics, I'm not into plastics, I'm not into aesthetics, I'm here to improve your quality of life through function and form not through, you know, a Kim K butt. 

Dr. Tea  27:25  
So the doctor who's listening right now, we want to show them guidance and make sure they understand what they're getting themselves into direct care. It's not all rainbows and unicorns and you know, sunshine, but do you think it's worth it?

Dr. Penhallow  27:41  
Absolutely. There's, there's, I wouldn't be in medicine, I would find something else to do. I do real estate or something, you know, in terms of investing to build up an active and passive portfolio or something different. And but this is what's kept me in Medicine, having the ability to not deal with a middleman, cut out middlemen, do things, practice on my terms, get my patients better and spend the amount of time I want to spend with my patients. And it's been fantastic. And it's been one of the steepest learning curves. But if not, you know, med school hard businesses not med school hard. So it's totally doable. And I do recommend exploring it, putting yourself with some mentors, gravitating towards others who are doing it so you don't feel like you're swimming in the sea alone. But it's absolutely worth it.

Dr. Tea  28:36  
Any last words, you want to mention to the listeners about your personal experience or any advice you'd like to give,

Dr. Penhallow  28:41  
Remain open to meeting with people read, you know, that open mind, you never know where that relationship could go in terms of that could be your next great megaphone of a patient that sends people your way. Or it could be somebody that you didn't even know had this skill, but then they connect you this other way that it's just there's a web that is woven, so don't take people on face value, get to know them. Explore, and keep that open mind.

Dr. Tea  29:15  
Thank you so much for being here on the podcast. I really appreciate all that you have to share. And I look forward to us connecting in real life hopefully soon. Thanks to everybody who's listening. If you have any questions, catch me in the show notes information down below, including Dr. Tammy Penhallow’s information. Also give her a connect on LinkedIn, we are actively engaging in conversations on direct care there. So that's a good place for us to get started with our connections. Thanks so much for listening. I'll catch you guys next week. Take care.

Dr. Tea  29:47  
Thank you so much for being here with me. If you enjoyed this episode and want to hear more, please like, share and subscribe so more people like you can have access to another way of practicing medicine. That direct care way less Disconnect find my info in the show notes and send me your questions that might be the topic for future episodes. 

Dr. Tea  30:06  
And lastly if you remember nothing else remember this be the energy you want to attract See you next time